Documents
First, A Word of Welcome
Welcome to Sanctuary Counseling Group. We are glad that you have chosen us and look forward to providing you with the quality of care and professionalism that we offer to each person who seeks help within the sanctuary of our offices. We are a faith based/spiritually centered organization, and we have expertise in including your faith/spiritual beliefs and practices as a part of the therapeutic process. It is our philosophy to work within the belief system and cultural framework of our patients.
It is our intention to provide you with sensitive, compassionate, and quality trained psychotherapists. The board of directors of SCG is committed to offering our services at a competitive rate, and in circumstances where the need is merited, our clinicians are able to offer our services on a sliding scale basis. Our ability to keep our rates affordable and to offer a sliding scale is due in large measure to the responsibility of persons like yourself. Payment is expected at the time of service. Payment in a timely manner allows us to keep our overhead low and with that, our rates are able to remain competitive and affordable. Because the appointment time is reserved for you, a FULL FEE may be charged for cancellations that occur within 24 hours of a scheduled appointment or for a missed appointment. A credit card is required and will be kept on file in the event of this occurrence.
Should you desire to utilize personal healthcare insurance, we will be happy to file on your behalf. Insurers require that we charge our regular fee, and you will be responsible for your copay amount, again payable at the time of service. In some cases, a deductible amount may apply, in which case you will be responsible for the deductible amount until it has been met, at which time your benefits will then be able to be utilized. Filing insurance does mean that you will be responsible for whatever portion of the fee is not covered by your insurance benefit. Please make certain that you understand your benefits for Mental Health in an office setting. You may do this by contacting your insurance provider. Should you have any additional questions regarding billing, please contact our business office at 704.375.5354.
Our goal is to make your journey with us as beneficial and as meaningful as possible. We are grateful for the trust you have placed in us and the quality of care that we provide. Our trained clinicians, along with our administrative staff are here to help you. Thank you again and welcome to Sanctuary Counseling Group.
John V. Arey, Jr., D.Min.
Executive Director
Martha K. Rick
SCG Board Chair
Prior to Your First Session …
Sanctuary Counseling Groups requires a number of forms in order to best serve the needs of our clients. The forms will vary depending on which therapist you are scheduled to see.
PLEASE SCROLL TO THE THERAPIST YOU WILL BE SEEING to manage the appropriate paperwork.
These documents in .pdf format are presented for your convenience and to save time during your initial appointment. Print them, fill them out, and bring them with you to your first session.
John Arey, D.Min.
The documents below are required for sessions with Dr. John Arey. Please download/print these documents, fill them out, and bring them to your initial sessions.
Intake Form — Required for all adult clients. For intakes who are minors, click here.
HIPAA Statement — For all clients
Demographic Information — For all clients; this will help us provide the best care that we can. The form is totally anonymous.
Jay Cobb, M.A.
The documents below are required for sessions with Jay Cobb. Please download/print these documents, fill them out, and bring them to your initial sessions.
- Intake Form — Required for all adult clients. For intakes who are minors, click here.
Jay Cobb PDS (NC LPCA) — Professional Disclosure Statement- HIPAA Statement — For all clients
- Demographic Information — For all clients; this will help us provide the best care that we can. The form is totally anonymous.
Garry Cook, M.S.W.
The documents below are required for sessions with Garry Cook. Please download/print these documents, fill them out, and bring them to your initial sessions.
- Intake Form — Required for all adult clients. For intakes who are minors, click here.
- HIPAA Statement — For all clients
- Demographic Information — For all clients; this will help us provide the best care that we can. The form is totally anonymous.
Shelton Davis, M.A.
The documents below are required for sessions with Shelton Davis. Please download/print these documents, fill them out, and bring them to your initial sessions.
- Intake Form — Required for all adult clients. For intakes who are minors, click here.
- Shelton Davis PDS (NC LPC) — Professional Disclosure Statement
- HIPAA Statement — For all clients
- Demographic Information — For all clients; this will help us provide the best care that we can. The form is totally anonymous.
Jonathan Golden, Ph.D.
The documents below are required for sessions with Dr. Jonathan Golden. Please download/print these documents, fill them out, and bring them to your initial sessions.
- Intake Form — Required for all adult clients. For intakes who are minors, click here.
Jonathan Golden PDS (NC LPC) — Professional Disclosure Statement- HIPAA Statement — For all clients
- Demographic Information — For all clients; this will help us provide the best care that we can. The form is totally anonymous.
Eddie Ingram, M.S.W.
The documents below are required for sessions with Eddie Ingram. Please download/print these documents, fill them out, and bring them to your initial sessions.
- Intake Form — Required for all adult clients. For intakes who are minors, click here.
- HIPAA Statement — For all clients
- Demographic Information — For all clients; this will help us provide the best care that we can. The form is totally anonymous.
Mark Larson, D.Min.
The documents below are required for sessions with Dr. Mark Larson. Please download/print these documents, fill them out, and bring them to your initial sessions.
- Intake Form — Required for all adult clients. For intakes who are minors, click here.
Mark Larson PDS (NC LPC) — Professional Disclosure Statement- HIPAA Statement — For all clients
- Demographic Information — For all clients; this will help us provide the best care that we can. The form is totally anonymous.
Todd Matson, D.Min.
The documents below are required for sessions with Dr. Todd Matson. Please download/print these documents, fill them out, and bring them to your initial sessions.
- Intake Form — Required for all adult clients. For intakes who are minors, click here.
- HIPAA Statement — For all clients
- Demographic Information — For all clients; this will help us provide the best care that we can. The form is totally anonymous.
Adrianna Serban, Psy.D.
The documents below are required for sessions with Dr. Adrianna Serban. Please download/print these documents, fill them out, and bring them to your initial sessions.
- Intake Form — Required for all adult clients. For intakes who are minors, click here.
- HIPAA Statement — For all clients
- Demographic Information — For all clients; this will help us provide the best care that we can. The form is totally anonymous.
Stacey Watkins-Griffith, D.Min.
The documents below are required for sessions with Dr. Stacey Watkins-Griffith. Please download/print these documents, fill them out, and bring them to your initial sessions.
- Intake Form — Required for all adult clients. For intakes who are minors, click here.
- Stacey Watkins-Griffith PDS (NCFBPPC) — Professional Disclosure Statement
- HIPAA Statement — For all clients
- Demographic Information — For all clients; this will help us provide the best care that we can. The form is totally anonymous.
Patricia Wells, Psy.D.
The documents below are required for sessions with Dr. Patricia Wells. Please download/print these documents, fill them out, and bring them to your initial sessions.
- Intake Form — Required for all adult clients. For intakes who are minors, click here.
- Patricia Hawkins Wells PDS (NCFBPPC) — Professional Disclosure Statement
- HIPAA Statement — For all clients
- Demographic Information — For all clients; this will help us provide the best care that we can. The form is totally anonymous.
Shannon White, M.A.
The documents below are required for sessions with Shannon White. Please download/print these documents, fill them out, and bring them to your initial sessions.
- Intake Form — Required for all adult clients. For intakes who are minors, click here.
- Shannon White PDS (NC LPC) — Professional Disclosure Statement
- HIPAA Statement — For all clients
- Demographic Information — For all clients; this will help us provide the best care that we can. The form is totally anonymous.
